CHAPTER 76
EXTERNAL REVIEW
191—76.1(84GA,HF597) Purpose. This chapter is intended to implement 2011 Iowa Acts, House File 597, to provide a uniform process for covered persons of health carriers providing health insurance coverage or the covered persons’ authorized representatives to request and receive an external review of adverse determinations and final adverse determinations as defined in 2011 Iowa Acts, House File 597, sections 2(1) and 2(18), and as referenced in 2011 Iowa Acts, House File 597, section 9(1). Health carriers defined in 2011 Iowa Acts, House File 597, section 2(23), are subject to these rules.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.2(84GA,HF597) Applicable law. The rules contained in this chapter shall apply to any health benefit plan as defined in 2011 Iowa Acts, House File 597, section 2(19), offered or issued by a health carrier as defined in 2011 Iowa Acts, House File 597, section 2(23), subject to the limitations set forth in 2011 Iowa Acts, House File 597, section 3(2), if the covered person is an Iowa resident or if the plan was issued in Iowa, and if the external review request is filed with the commissioner on or after July 1, 2011. For purposes of applying the exemption in 2011 Iowa Acts, House File 597, section 3(2)“b,” a “Medicare supplement policy of insurance” shall mean the same as a “Medicare supplement policy” as defined in rule 191—37.3(514D). For purposes of this chapter, the definitions used in 2011 Iowa Acts, House File 597, shall be used in this chapter.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.3(84GA,HF597) External review request. Except for requests for expedited review, the covered person or the covered person’s authorized representative shall send a request for external review (completed Appendix B) in writing, by mail, by fax or by electronic transmission, including a copy of the health carrier’s written notice containing the final adverse determination, to the commissioner within the time periods specified in 2011 Iowa Acts, House File 597, section 7(1) or 9(1), as applicable. The request form and notice shall be sent to the commissioner at Insurance Division, 330 Maple Street, Des Moines, Iowa 50319; fax (515)281-3059; or E-mail iid.marketregulation@iid.iowa.gov.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.4(84GA,HF597) Decision notification. The independent review organization shall immediately provide a copy of a draft of the decision notification to the commissioner for review. The commissioner shall review the draft of the decision notification. The commissioner shall make any suggestions for changes. The independent review organization shall make such required changes. Once the commissioner determines that the decision notification meets the requirements of 2011 Iowa Acts, House File 597, section 7(12), 8(6), or 9(18), as applicable, the independent review organization shall immediately send the decision notification to the commissioner, the health carrier, and the covered person or covered person’s authorized representative. The decision notification approved by the commissioner shall be delivered by telephone, fax or electronic transmission, and a hard copy of the decision notification also shall be delivered by regular mail.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.5(84GA,HF597) Disclosure requirements. The description of external review procedures required by 2011 Iowa Acts, House File 597, section 16, shall be in the form of Appendix A, or substantially similar language approved by the commissioner.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.6(84GA,HF597) Health carrier information.
	76.6(1) Each health carrier shall provide to the commissioner the name, title, telephone number, fax number and E-mail address of the individual who shall be the health carrier’s contact person for external review procedures. Any changes in personnel or communication information shall be immediately sent to the commissioner.
	76.6(2) Each health carrier shall make available to the commissioner upon request within five business days a detailed description of the process the health carrier has in place to ensure compliance with the requirements found in this chapter and in 2011 Iowa Acts, House File 597. The description shall include:
	a. 	An explanation of how the carrier determines when a person has qualified for external review and should receive a notice from the carrier or organized delivery system, and
	b. 	A copy of the notice sent to persons who fall within the scope of the law.
	76.6(3) Each health carrier shall provide to the commissioner, upon request, information set forth in 2011 Iowa Acts, House File 597, section 14(2)“b,” in a format substantially similar to Appendix D, or as approved by the commissioner.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
191—76.7(84GA,HF597) Certification of independent review organization.
	76.7(1) In addition to the minimum qualifications set forth in 2011 Iowa Acts, House File 597, section 12, the following minimum standards are required for certification as an independent review organization:
	a. 	The applicant shall provide a description of the procedures employed to comply with 2011 Iowa Acts, House File 597, section 12(1)“a.”
	b. 	The applicant shall provide the number of reviewers retained by the independent review organization and a description of the areas of expertise available from such reviewers and the types of cases such reviewers are qualified to review.
	c. 	The applicant shall provide the names and résumés of all directors, officers, and executives of the independent review organization.
	d. 	The applicant shall provide a description of the fees to be charged by the independent review organization for external reviews. Fees shall be reasonable in relation to those of other independent review organizations providing external review services in Iowa. A health carrier or the commissioner may object to a fee as unreasonable, and the commissioner or the commissioner’s designee, at the discretion of the commissioner, may conduct a review.
	e. 	The applicant shall provide the name of the medical director or health professional director responsible for the supervision and oversight of the independent review procedure.
	76.7(2) The independent review organization shall develop written policies and procedures to ensure adherence to the requirements of this chapter and 2011 Iowa Acts, House File 597, by any contractor, subcontractor, subvendor, agent or employee affiliated with the certified independent review organization.
	76.7(3) In addition to the toll-free telephone service required by 2011 Iowa Acts, House File 597, section 12(1)“b,” the independent review organization shall establish a facsimile and electronic mail service to receive information relating to external reviews pursuant to this chapter and 2011 Iowa Acts, House File 597.
	76.7(4) The independent review organization shall provide the commissioner within ten business days of request such data, information, and reports as the commissioner determines necessary to evaluate the external review process established under 2011 Iowa Acts, House File 597, or a report in the format of Appendix C to comply with 2011 Iowa Acts, House File 597, section 14(1).
	76.7(5) Applications shall be submitted to the Commissioner of Insurance, 330 Maple Street, Des Moines, Iowa 50319; or as designated by the commissioner. Applications must be submitted in full to be considered. All applicants will be notified of the certification decision. A list of certified independent review organizations shall be maintained by the commissioner and shall be available through the Web site of the Iowa insurance division: www.iid.state.ia.us.
[ARC 9637B, IAB 7/27/11, effective 7/8/11]
These rules are intended to implement 2011 Iowa Acts, House File 597.

[Filed 10/29/99, Notice 9/22/99—published 11/17/99, effective 12/22/99]
[Filed 4/10/00, Notice 1/12/00—published 5/3/00, effective 6/7/00]
[Filed 11/21/01, Notice 10/17/01—published 12/12/01, effective 1/16/02]
[Filed Emergency ARC 9637B, IAB 7/27/11, effective 7/8/11]